Fabrication of new restorations with a consideration of oral hygiene.

Maintenance of adequate and effective oral hygiene is crucial for the long-term success of any dental therapy. This article discusses a case that failed due to the poor oral hygiene of the patient. Fabrication of uncomplicated restorations, patient education, motivation, maintenance and recall are important factors to be considered when treatment planning patients with poor oral hygiene.

INTRODUCTION

The ability and motivation of the patient to maintain good oral hygiene is a key factor affecting the long-term prognosis of a restoration and prevention of biological complications.[12] Inadequate oral hygiene promotes the formation of biofilm causing inflammation of the soft tissue.[1] Persistent inflammation of the soft tissue results in the spread of infection to the bone causing deterioration of the osseous structures.[134] Inflammation and infection in the location of dental implants can lead to loss of osseointegration and failure of the implants.[156] In the vicinity of natural teeth, inflammation and infection may result in periodontitis and loss of teeth. The level of patient oral hygiene should be documented and continuously monitored before and during treatment.

Three main causes of poor oral hygiene are: Lack of motivation/awareness of the patient, complicated restorations and poor dexterity of the patient. Patients with lack of motivation/awareness should be educated and encouraged to improve their oral hygiene. It is important for the clinician to demonstrate correct oral hygiene procedures and incorporate oral hygiene devices as per each patient's situation into their oral hygiene regimen. Complicated restorations, such as connected multiunit and/or implant restorations often require additional hygiene techniques. Cagna, et al., have recommended incorporating an electric toothbrush with interchangeable brush heads for cleaning difficult areas associated with complex restorations.[1] The care givers of patients with poor dexterity should be educated regarding the maintenance of oral hygiene of the patient, as they will be required to perform the daily hygiene regimen.

When planning implant therapy in the edentulous patient, the type and design of the restoration should be selected considering the level of oral hygiene compliance the patient has demonstrated.[7] The intaglio surface contour and limited accessibility of a fixed implant-supported restoration require skill and time to clean. Removable implant supported restorations can be detached and more readily cleaned by a care-taker or patient with poor dexterity and/or oral hygiene compliance.[8] In addition, the choice of attachment is critical to success in the noncompliant patient. Patients with bar supported implant overdentures may develop mucosal hyperplasia beneath the bar and mucositis around the implants.[910111213141516] Reduced tissue coverage of unsplinted, free-standing attachments such as Locators (Zest Anchors) or ERA attachments (Sterngold) make them a better treatment choice than connected bars for patients with poor oral hygiene.[7]

Evaluation of the patient's oral hygiene compliance and motivation is essential to restoration design considerations. Even the most motivated patient requires extensive instruction in techniques and tools to maintain an acceptable level of hygiene. This article details a case report wherein a patient with poor oral hygiene was treatment planned with bar supported overdentures. The patient was not able to maintain hygiene underneath the bar which ultimately resulted in the failure of the restoration.

CASE REPORT

A 60-year-old Caucasian male came to the clinic with the chief compliant: “I am not able to eat and my teeth and implants hurt all the time.” Patient was a smoker with extremely poor oral hygiene. The patient presented with an open palate bar supported overdenture in the maxilla retained by six implants which were in service for 8 years. The patient had moved soon after denture delivery and failed to return to any dental practitioner for maintenance and recall.

Diagnostic impressions, intraoral images, and radiographs were made for the patient. Examination of the maxillary arch revealed mucosal hyperplasia and mucositis, gingival to the overdenture bar. The mucosal hyperplasia resulted in the loss of space between the bar and tissue [Figure 1]. The mucosa was very tender and inflamed. The radiographic evaluation indicated that the mucositis had extended to the bone resulting in chronic peri-implantitis. Two of the six implants had severe peri-implantitis and were deemed to be in failure. The mandibular teeth were covered with calculus, heavily stained, were affected by caries and severe generalized chronic periodontitis. Patient was aware that his remaining lower teeth were not restorable. Poor oral hygiene was identified as the main causative factor in the degradation of the dental tissues.

Figure 1

Mucosal hyperplasia underneath the maxillary bar

The patient was explained in detail that his problems were related to his poor oral hygiene and lack of professional maintenance. Patient was thoroughly educated regarding the importance of adequate and effective oral hygiene on the long-term success of the new restorations. Once the patient committed to maintaining his hygiene and his restorations a treatment plan was formulated for the patient as follows:

For the mandible

Extraction of mandibular teeth

Placement of two to four implants in the mandible

Fabrication of implant supported overdenture for the mandible

Unsplinted attachments (Locators, Zest Anchors)

Strict maintenance and recall [Table 1].

Table 1

Recall schedule for the patient

For the maxilla

Removal of hypertrophied tissue underneath the maxillary bar

Removal of two compromised maxillary implants

Treatment of remaining maxillary implants

Unsplinted attachments (Locators, Zest Anchors)

Fabrication of implant supported overdenture for the maxilla

Strict maintenance and recall [Table 1].

Patient consented to the treatment. He was referred to the periodontist for removal of the hypertrophied tissue, removal of compromised implants, extraction of all mandibular teeth and for the treatment of remaining implants. The periodontist educated and reemphasized oral hygiene to the patient. Upon subsequent visits during the treatment phase, patient hygiene compliance was noted by a visible decrease in plaque and inflammation. Once the procedures were performed, the disease was controlled and treated, and the ridges healed the patient was referred back to the author for fabrication of restorations. The remaining four maxillary implants were parallel to each other and were stable. Having factored in the past history of poor oral hygiene of the patient and his desire for an easily maintained restoration it was concluded that the bar supported overdenture was not the optimal restoration for this patient. New maxillary implant overdenture was fabricated for this patient using free standing attachments (Locators, Zest Anchors) following current best practice procedures [Figure 2]. The antero-posterior spread of the implants did not permit an open palate denture.[17] A complete palate overdenture was fabricated for the patient. Metal framework was incorporated in the denture to permit the reduction of thickness of the denture in the palate, to improve fit and aid in thermal stimulation[18] [Figure 3]. A transitional restoration (conventional mandibular removable dental prosthesis) was fabricated for the lower arch. The restorations were adjusted as needed and delivered to the patients. Oral hygiene instructions were given to the patient [Appendix 1] [Figures 4 and 5]. During recall visits, the patient demonstrated adequate ability to clean the abutments, denture bearing tissue and dentures effectively. The patient was pleased with the result [Figure 6] and was recalled regularly [Table 1] to avoid further complications.

Figure 2

Individual stud abutments attached to the maxillary implants

Figure 3

Metal framework incorporated in maxillary overdenture

Figure 4

Use of unitufted brush to clean individual attachments

Figure 5

Soft bristle brush used to clean and stimulate denture bearing mucosa

Figure 6

Patient's smile with the new restorations

CONCLUSION

Patient's ability to perform regular and effective personal oral hygiene impacts the long-term success of therapy. Patients should be educated prior to the commencement of the proposed treatment to avoid future complications. Many restorations present with contours and spaces that are difficult to clean. Patients who are incapable of maintaining optimal oral hygiene should not be restored with such complex restorations.